Provider Demographics
NPI:1003462359
Name:DREW, JONATHON VIRTUS
Entity Type:Individual
Prefix:
First Name:JONATHON
Middle Name:VIRTUS
Last Name:DREW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5851 SACRAMENTO AVE
Mailing Address - Street 2:
Mailing Address - City:ALTA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91701-2723
Mailing Address - Country:US
Mailing Address - Phone:909-727-4616
Mailing Address - Fax:
Practice Address - Street 1:12235 BEACH BLVD STE 100
Practice Address - Street 2:
Practice Address - City:STANTON
Practice Address - State:CA
Practice Address - Zip Code:90680-3943
Practice Address - Country:US
Practice Address - Phone:714-202-0118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-13
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst